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The cardiovascular effect of smoking bans in Europe 

Junk science, or the way to go?

Topics: Cardiovascular Disease Prevention - Risk Assessment and Management
Date: 02 Sep 2009
Smoking bans in countries like France or Scotland – where a cigarette or two seemed part of café culture – have been accepted, even welcomed, with surprising ease.

© European Communities, 2009There were no riots in public bars, few “patrons” complaining that their cafés were empty. And those who couldn’t resist a cigarette simply stepped outside for a while. But there were protests.
The most vocal complaint of the pro-smoking, anti-prohibition lobby is that the studies which seem to validate our smoking bans – whether local or national – are no better than pseudo science, or “junk science” as their protest placards would have us believe. Indeed, even one of the bigger studies of this kind – the Scottish StopIt study from Pell and colleagues published in the New England Journal of Medicine last year – was described in a BBC review as “over-hasty and over-confident research” when it was first presented at a conference. 

The issue which - for some - reduces these studies to junk is causation, and with it the basic epidemiological conundrum of when statistical association becomes an unequivocal cause and effect. For critics of the smoking bans, none of the studies reported prove causation (that a smoking ban actually lowers the incidence of heart disease), and are so replete with confounding that any valid conclusion is impossible.

Yet the fact is that every study so far reported on the effect of smoking bans does indeed show a lowering of hospital admissions or death from CHD.

  • In February last year the French authorities announced a 15% decrease in emergency admissions for AMI just one year after the public ban on smoking came into effect.
  • Similar results were reported from Italy when researchers in Rome found an 11.2% reduction of acute coronary events since a January 2005 smoking ban among patients under 65.
  • Researchers from Ireland, where a public smoking ban was introduced in 2004, found a reduction of 11% in admissions with acute coronary events in the year following the ban, which was sustained through the following year.

The Scottish StopIt study, which monitored the effects of legislation introduced in March 2006, reported a 17% reduction in hospitalisations for ACS - as compared with a 4% reduction in England, where no such legislation was in place at the time, over a ten-month study period. The investigators noted that this decrease was much greater than the underlying trend (there was a mean annual decrease of 3% in ACS admissions during the decade before the study). They also reported that cotinine assays in non-smoking adults in Scotland confirmed a reduced overall exposure to smoke of 42%, a reduction not dissimilar to the 47% reduction reported in New York after their enactment of smoke-free legislation.

Similarly, a recent meta-analysis of eight studies on the effects of smoke-free legislations (four from US states, two from Italy and one from Canada and Ireland) concluded that they yielded “an immediate 19% reduction” in AMI admission rates “associated with these laws”.

Total bans on smoking in all enclosed public places and workplaces in Europe, including bars and restaurants, are so far enforced only in Ireland and UK. Legislation in Italy, Malta, Sweden, Latvia, Finland, Slovenia, France and the Netherlands allows for special enclosed smoking rooms.

Professor Erika Froelicher from the University of California, San Francisco, who spoke at a Symposium on smoking cessation last Sunday, says that in Europe and all states of the USA the smoking bans have been “highly successful,” but not everywhere in the world. “It’s a matter of enforcement,” she says. “In those parts of the world where smoking bans are ignored and not enforced, they’re having little effect.”

For Professor Froelicher, an epidemiologist and clinical nurse specialist, the enforcement of smoking bans by legislation should be part of a range of measures designed to discourage smoking and exert peer pressure that it’s simply a bad habit. As part of that range, raising the price of cigarettes – mainly through taxation – “is the single most successful way,” but she also emphasises the importance of personal intervention and the role of nurses and physicians. “Healthcare professionals do not show sufficient inclination to intervene,” she says. “It’s relatively straightforward, and counseling is an important option.”

For her part, Professor Jill Pell from Glasgow University, first author of the StopIt study, has recently concluded (in a June review for the journal Heart) that “there is increasing evidence that [smoke-free legislation] reduces the risk of cardiovascular disease” and that “we have good reason to believe that the early beneficial effects will be maintained in the longer-term and may even increase”.  

Authors: Simon Brown
ESC Congress News

Notes to editor

Hot spots – and not so hot – of a smoke-free Europe

The legislative framework for modern tobacco control was set out in 2003 when the WHO ratified its first public health treaty, the Framework Convention on Tobacco Control, whose Article 8 has so far been adopted by more than 160 countries worldwide, including all EU member states (except Czech Republic).

  • Ireland

Ireland became the first country in the world to be 100% smoke free in March 2004. Smoking is banned in enclosed or more than 50% enclosed public places and workplaces (including all bars, cafés and restaurants). Designated smoking rooms are not allowed.

  • United Kingdom

England became smoke free in July 2007. The entire UK is now smoke free, making it the world’s most populated smoke-free jurisdiction. Smoking is prohibited in enclosed or substantially enclosed public places and workplaces. In March 2006, Scotland became the first region in the UK to introduce 100% smoke-free legislation.

  • France

Smoke-free legislation came into effect in France in February 2007 to include all public places and workplaces; bars and restaurants were exempted until 1 January 2008.

  • Spain

Smoke-free legislation came into effect in Spain in January 2006, with smoking banned in enclosed public places and workplaces; however, exemptions were allowed for restaurants and bars of less than 100 m2; smoking rooms were allowed otherwise.

  • Germany

At the national level smoking was banned in government buildings and on public transport (and stations) in September 2007. Smoke-free laws exist in all states, but none are total. There is still legal debate as to whether a total ban is constitutional.

  • Sweden

All public places and workplaces in Sweden, including restaurants and bars, became smoke free on 1 June 2005.

  • Austria

Smoking is banned in schools and public transport but not in all workplaces or bars and restaurants. The law is poorly enforced but new legislation requires the latter to provide non-smoking rooms.

  • Czech Republic

As of January 2006 smoking is forbidden in most public places, and restaurants must provide smoking areas. In June this year Czech MPs backed a proposal allowing bars and restaurants owners to decide whether their establishments are smoke free or not.

  • Italy

Italian law introduced in January 2005 banned smoking in all indoor public places. Smoking areas must be enclosed and ventilated.

  • Greece

Fragile non-smoking laws are largely ignored, but a new law based on a model like Spain’s will require bars and restaurants to provide sealed smoking areas. According to research carried out for the EuroHeart project, Greece is one of only two countries to have no national policy relating specifically to CHD – and where there seems a clear association between disease incidence and government policy.

  • Poland

Only limited legislation in place, but measures now before Parliament (proposed by the Health Committee) to introduce a comprehensive ban in all public places.

  • Netherlands

Legislation of 2004 made smoking illegal in workplaces – but with exceptions, which included bars and restaurants. These were included in 2008 legislation, but there have been legal challenges (particularly by small cafés) in some cities.